2018 Improvement Activities

All Improvement Activities (IA) can be easily attested to with MDinteractive.

Log into your account

Click on Add/Edit next to the IA category. This will direct you to the IA reporting module. Note that you might have to enter your NPI/TIN combination or just TIN (if reporting as a group) to be able to see the categories and Add/Edit.

Enter your minimum 90 day reporting period

Click “Add” to each activity that you performed for at least 90 consecutive days:

Note: There are frequency restrictions associated with the following Improvement Activities: IA_PSPA_4, IA_PSPA_22, IA_PSPA_23, and IA_PSPA_24. Please review documentation/rules for these activities prior to attesting to them in 2018.

Each activity is weighted either medium or high.

To achieve the maximum 40 points for the Improvement Activity score:

A clinician (that works in a group with 15 or fewer providers billing with the same TIN) may select either of these combinations:

1 high-weighted activity OR

2 medium-weighted activities

Clincians working on larger groups will need to attest to more activities to receive full credit for this category:

2 high-weighted activities OR

1 high-weighted activity and 2 medium-weighted activities OR

4 medium-weighted activities

ID: IA_EPA_1

Weighting: High

Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record

Subcategory Name:

Expanded Practice Access

Activity Description:

• Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:• Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);• Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or Provision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management.

Activity Validation:

Functionality of 24/7 or expanded practice hours with access to medical records or ability to increase access through alternative access methods or same-day or next-day visits

Suggested Documentation:

1) Patient Record from EHR - A patient record from a certified EHR with date and timestamp indicating services provided outside of normal business hours for that clinician; or2) Patient Encounter/Medical Record/Claim - Patient encounter/medical record claims indicating patient was seen or services provided outside of normal business hours for that clinician including use of alternative visits; or3) Same or Next Day Patient Encounter/Medical Record/Claim - Patient encounter/medical record claims indicating patient was seen same-day or next-day to a consistent clinician for urgent or transitional care

ID: IA_EPA_2

Weighting: Medium

Use of telehealth services that expand practice access

Subcategory Name:

Expanded Practice Access

Activity Description:

Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients.

Activity Validation:

Documented use of telehealth services and participation in data analysis assessing provision of quality care with those services

Suggested Documentation:

1) Use of Telehealth Services - Documented use of telehealth services through: a) claims adjudication (may use G codes to validate); b) certified EHR or c) other medical record document showing specific telehealth services, consults, or referrals performed for a patient; and 2) Analysis of Assessing Ability to Deliver Quality of Care - Participation in or performance of quality improvement analysis showing delivery of quality care to patients through the telehealth medium (e.g. Excel spreadsheet, Word document or others)

ID: IA_EPA_3

Weighting: Medium

Collection and use of patient experience and satisfaction data on access

Subcategory Name:

Expanded Practice Access

Activity Description:

Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.

Activity Validation:

Development and use of access to care improvement plan based on collected patient experience and satisfaction data

As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services (e.g., investment of on-site diabetes educator).

Activity Validation:

Implementation of additional processes, practices, resources or technology to improve access to services, as a result of receiving QIN/QIO technical assistance

Suggested Documentation:

1) Relationship with QIN/QIO Technical Assistance - Confirmation of technical assistance and documentation of relationship with QIN/QIO; and2) Improvement Activities - Documentation of activities that improve access including support on additional services offered

ID: IA_EPA_5

Weighting: Medium

Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)

Subcategory Name:

Expanded Practice Access

Activity Description:

User participation in the Quality Payment Program website testing is an activity for eligible clinicians who have worked with CMS to provided substantive, timely, and responsive input to improve the CMS Quality Payment Program website through product user-testing that enhances system and program accessibility, readability and responsiveness as well as providing feedback for developing tools and guidance thereby allowing for a more user-friendly and accessible clinician and practice Quality Payment Program website experience.

ID: IA_PM_1

Weighting: High

Participation in Systematic Anticoagulation Program

Subcategory Name:

Population Management

Activity Description:

Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program) for 60 percent of practice patients in the transition year and 75 percent of practice patients in Quality Payment Program Year 2 and future years, who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors).

Activity Validation:

Documented participation of patients in a systematic anticoagulation program. Could be supported by claims.

Suggested Documentation:

1) Patients Receiving Anti-Coagulation Medications - Total number of patients receiving anti-coagulation medications; and2) Percentage of that Total Participating in a Systematic Anticoagulation Program - Documented number of referrals to a coagulation/anti-coagulation clinic; number of patients performing patient self-reporting (PST); or number of patients participating in self-management (PSM).

ID: IA_PM_2

Weighting: High

Anticoagulant Management Improvements

Subcategory Name:

Population Management

Activity Description:

Individual MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, for 60 percent of practice patients in the transition year and 75 percent of practice patients in Quality Payment Program Year 2 and future years, their ambulatory care patients receiving warfarin are being managed by one or more of the following improvement activities:

• For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.

Activity Validation:

Documented participation of patients being managed by one or more clinical practice improvement activities. Could be supported by claims.

Suggested Documentation:

1) Patients Receiving Anti-Coagulation Medications - Total number of outpatients prescribed oral Vitamin K antagonist therapy; and2) Percentage of that Total Being Managed By a Clinical Practice Improvement Activity - Number of outpatients prescribed oral Vitamin K antagonist therapy and who are being managed by one or more of the four activities in the described in the activity description

ID: IA_PM_3

Weighting: High

RHC, IHS or FQHC quality improvement activities

Subcategory Name:

Population Management

Activity Description:

Participating in a Rural Health Clinic (RHC), Indian Health Service Medium Management (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.

1) Name of RHC, HIS or FQHC - Identified name of RHC, IHS, or FQHC in which the practice participates in ongoing engagement activities; and 2) Continuous Quality Improvement Activities - Documented continuous quality improvement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality and benchmarking improvement that ultimately benefits patients

ID: IA_PM_4

Weighting: High

Glycemic management services

Subcategory Name:

Population Management

Activity Description:

For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having:For the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that:a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, and b) Is reassessed at least annually.

The performance threshold will increase to 75 percent for the second performance year and onward. Clinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.

Activity Validation:

Report listing patients who are diabetic and prescribed antidiabetic agents and have documented glycemic treatment goals based on patient-specific factors

Suggested Documentation:

1) Diabetic Patients Prescribed Antidiabetic Agents - Total number of outpatients who are diabetic and prescribed antidiabetic agents; and2) Documented Percentage of Total with Glycemic Treatment Goals and Assessed at Least Annually - Number of outpatients, who are diabetic and prescribed antidiabetic agents, with documented glycemic treatment goals ; and the goals take into account patient-specific factors, including at least age, comorbidities, and risk for hypoglycemia; and are flagged for reassessment in following year.

ID: IA_PM_5

Weighting: Medium

Engagement of community for health status improvement

Subcategory Name:

Population Management

Activity Description:

Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

Activity Validation:

Activity to improve specific chronic condition within the community is being undertaken

Suggested Documentation:

1) Documentation of Partnership in the Community - Screenshot of website or other correspondence identifying key partners and stakeholders and relevant initiative including specific chronic condition; and2) Steps for Improving Community Health Status - Report detailing steps being taken to satisfy the activity including, e.g., timeline, purpose, and outcome that is in compliance with the local QIO

ID: IA_PM_6

Weighting: Medium

Use of toolsets or other resources to close healthcare disparities across communities

Subcategory Name:

Population Management

Activity Description:

Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.

Activity Validation:

Involvement with a QCDR to generate local practice patterns and outcomes reports including vulnerable populations

Suggested Documentation:

Participation in QCDR for population health, e.g., regular feedback reports provided by QCDR that summarize local practice patterns and treatment outcomes, including vulnerable populations

ID: IA_PM_9

Weighting: Medium

Participation in population health research

Subcategory Name:

Population Management

Activity Description:

Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.

Activity Validation:

Involvement in research to improve targeted patient population

Suggested Documentation:

Documentation confirming participation in research that identifies interventions, tools or processes that can improve a targeted patient population, e.g. email, correspondence, shared data, or research reports

ID: IA_PM_10

Weighting: Medium

Use of QCDR data for quality improvement such as comparative analysis reports across patient populations

Subcategory Name:

Population Management

Activity Description:

Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).

Activity Validation:

Participation and use of QCDR, clinical data or other registries to improve quality of care

Suggested Documentation:

Participation in QCDR for quality improvement across patient populations, e.g., regular feedback reports provided by QCDR using data for quality improvement such as comparative analysis reports across patient populations

ID: IA_PM_11

Weighting: Medium

Regular Review Practices in Place on Targeted Patient Population Needs

Subcategory Name:

Population Management

Activity Description:

Implementation of regular reviews of targeted patient population needs, such as structured clinical case reviews, which includes access to reports that show unique characteristics of eligible clinician's patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.

Activity Validation:

Participation in reviews of targeted patient population needs including access to reports and community resources

Suggested Documentation:

1) Targeted Patient Population Identification - Documentation of method for identification and ongoing monitoring/review for a targeted patient population; and2) Report with Unique Characteristics - Reports that show unique characteristics of patient population and identification of vulnerable patients; and3) Tailored Clinical Treatments - Medical records demonstrating ways clinical treatment needs are being tailored to meet unique needs including additional community resources, if necessary

ID: IA_PM_12

Weighting: Medium

Population empanelment

Subcategory Name:

Population Management

Activity Description:

Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.Empanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management.Empanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the “active population” of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define “active patients” operationally, but generally, the definition of “active patients” includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.

Activity Validation:

Functionality of patient population empanelment including use of panels for health management

Suggested Documentation:

1) Active Population Empanelment - Identification of "active population" of the practice with empanelment and assignment confirmation linking patients to MIPS eligible clinician or care team; and2) Process for Updating Panel - Process for review and update of panel assignments

ID: IA_PM_13

Weighting: Medium

Chronic Care and Preventative Care Management for Empaneled Patients

Subcategory Name:

Population Management

Activity Description:

Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following:

• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;

• Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target; such as a CDC-recognized diabetes prevention program;

• Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions;

1) Individualized Plan of Care - Annual opportunity for development and/or adjustment of an individualized plan of care appropriate to age and health status; or2) Condition-Specific Pathways - Use of condition-specific pathways for chronic conditions with evidence-based protocols, or3) Pre-visit Planning - Use of pre-visit planning to optimize preventive care and team management; or4) Panel Support Tools - Use of panel support tools to identify services that are due; or5) Reminders and Outreach - Use of reminders and outreach to alert and educate patients about services due; or6) Medication Reconciliation - Use of routine medication reconciliation

ID: IA_PM_14

Weighting: Medium

Implementation of methodologies for improvements in longitudinal care management for high risk patients

Subcategory Name:

Population Management

Activity Description:

Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following:Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification;Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/orUse on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.

Activity Validation:

Longitudinal care management to patients at high risk for adverse health outcome or harm

Suggested Documentation:

1) High Risk Patients - Identification of patients at high risk for adverse health outcome or harm; and2) Use of Longitudinal Care Management - Documented use of longitudinal care management methods including at least one of the following: a) empaneled patient risk assignment and risk stratification into actionable risk cohorts; or b) personalized care plans for patients at high risk for adverse health outcome or harm; or c) evidence of use of on-site practice based or shared care managers to monitor and coordinate care for highest risk cohort

ID: IA_PM_15

Weighting: Medium

Implementation of episodic care management practice improvements

Subcategory Name:

Population Management

Activity Description:

Provide episodic care management, including management across transitions and referrals that could include one or more of the following:Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/orManaging care intensively through new diagnoses, injuries and exacerbations of illness.

1) Follow-Up on Hospitalizations, ED or Other Visits and Medication Management - Routine and timely follow-up to hospitalizations, ED or other institutional visits, and medication reconciliation and management (e.g. documented in medical record or EHR); or2) New diagnoses, Injuries and Exacerbations - Care management through new diagnoses, injuries and exacerbations of illness (medical record)

ID: IA_PM_16

Weighting: Medium

Implementation of medication management practice improvements

Subcategory Name:

Population Management

Activity Description:

Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following:Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups;Integrate a pharmacist into the care team; and/orConduct periodic, structured medication reviews.

Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.

ID: IA_PM_18

Weighting: Medium

Provide Clinical-Community Linkages

Subcategory Name:

Population Management

Activity Description:

Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency. This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes. An example of this community based program is the NCQA Patient-Centered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.

ID: IA_PM_19

Weighting: Medium

Glycemic Screening Services

Subcategory Name:

Population Management

Activity Description:

For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the 2018 performance period and 75 percent in future years, of electronic medical records with documentation of screening patients for abnormal blood glucose according to current US Preventive Services Task Force (USPSTF) and/or American Diabetes Association (ADA) guidelines.

ID: IA_PM_20

Weighting: Medium

Glycemic Referring Services

Subcategory Name:

Population Management

Activity Description:

For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of medical records with documentation of referring eligible patients with prediabetes to a CDC-recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.

ID: IA_PM_21

Weighting: Medium

Advance Care Planning

Subcategory Name:

Population Management

Activity Description:

Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.

ID: IA_CC_1

Weighting: Medium

Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop

Subcategory Name:

Care Coordination

Activity Description:

Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.

Implementation of additional activity as a result of TA for improving care coordination

Subcategory Name:

Care Coordination

Activity Description:

Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.

Activity Validation:

Implementation of at least one recommended QIN-QIO activity related to care coordination

Confirmation of participation in the Partnership for Patients Hospital Engagement Network (HEN) initiative for that year (e.g. CMS confirmation email)

ID: IA_CC_6

Weighting: Medium

Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination

Subcategory Name:

Care Coordination

Activity Description:

Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).

Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).

Activity Validation:

Processes and practices are implemented to improve care coordination

Suggested Documentation:

Documentation of the implementation of practices/processes that document care coordination activities, e.g., documented care coordination encounter that tracks clinical staff involved and communications from date patient is scheduled through day of procedure

Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.

Activity Validation:

Individual care coordination plans are regularly developed and updated for at-risk patients and shared with beneficiary or caregiver

Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.).

Activity Validation:

Patient-centered, care transition action plan for is carried out for first 30 days following a discharge

Suggested Documentation:

Documentation of care transition practices/processes including a patient-centered action plan for first 30 days following a discharge

ID: IA_CC_11

Weighting: Medium

Care transition standard operational improvements

Subcategory Name:

Care Coordination

Activity Description:

Establish standard operations to manage transitions of care that could include one or more of the following:

Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or

Partner with community or hospital-based transitional care services.

Activity Validation:

Functionality of information flow during transitions of care to ensure seamless transitions

Suggested Documentation:

1) Communication Lines with Local Settings - Documentation of formal lines of communication to manage transitions of care with local settings (e.g. community or hospital-based transitional care services) in which empaneled patients receive care to ensure documented flow of information and seamless transitions; or2) Partnership with Community or Hospital-Based Transitional Care Services - Documentation showing partnership with community or hospital-based transitional care services

Establish effective care coordination and active referral management that could include one or more of the following:

Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements;

Track patients referred to specialist through the entire process; and/orSystematically integrate information from referrals into the plan of care.

Activity Validation:

Functionality of effective care coordination and referral management

Suggested Documentation:

1) Care Coordination Agreements - Sample of care coordination agreements with frequently used consultant that establish documented flow of information and provides patients with information to set consistent expectations; or2) Tracking of Patient Referrals to Specialists - Medical record or EHR documentation demonstrating tracking of patients referred to specialists through the entire process; or3) Referral Information Integrated into the Plan of Care - Samples of specialist referral information systematically integrated into the plan of care

ID: IA_CC_13

Weighting: Medium

Practice Improvements for Bilateral Exchange of Patient Information

Subcategory Name:

Care Coordination

Activity Description:

Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following:

Practice Improvements that Engage Community Resources to Support Patient Health Goals

Subcategory Name:

Care Coordination

Activity Description:

Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following:

• Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and provide a guide to available community resources.

• Including through the use of tools that facilitate electronic communication between settings;

• Screen patients for health-harming legal needs;

• Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or

• Provide a guide to available community resources.

Activity Validation:

Availability of formal links to community-based health and wellness programs potentially including availability of resource guides

Suggested Documentation:

1) Community-Based Chronic Disease Self-Management Programs - Documentation of community-based chronic disease self-management support programs, exercise programs, and other wellness resources (including specific names) with which practices have formal referral links and have potential bidirectional flow of information; or2) Provision of Community Resource Guides - Medical record demonstrating provision of a guide to community resources

ID: IA_CC_15

Weighting: Medium

PSH Care Coordination

Subcategory Name:

Care Coordination

Activity Description:

Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physicianled, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:

The primary care and behavioral health practices use the same electronic health record system for shared patients or have an established bidirectional flow of primary care and behavioral health records.

ID: IA_CC_17

Weighting: High

Patient Navigator Program

Subcategory Name:

Care Coordination

Activity Description:

Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.

ID: IA_BE_1

Weighting: Medium

Use of certified EHR to capture patient reported outcomes

Subcategory Name:

Beneficiary Engagement

Activity Description:

In support of improving patient access, performing additional activities that enable capture of patient reported outcomes (e.g., home blood pressure, blood glucose logs, food diaries, at-risk health factors such as tobacco or alcohol use, etc.) or patient activation measures through use of certified EHR technology, containing this data in a separate queue for clinician recognition and review.

Activity Validation:

Functionality of patient reported outcomes in certified EHR

Suggested Documentation:

1) Patient Reported Outcomes in EHR - Report from the certified EHR, showing the capture of PROs or the patient activation measures performed; or2) Separate Queue for Recognition and Review - Documentation showing the call out of this data for clinician recognition and review (e.g. within a report or a screen-shot)

ID: IA_BE_2

Weighting: Medium

Use of QCDR to support clinical decision making

Subcategory Name:

Beneficiary Engagement

Activity Description:

Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision making capabilities.

Activity Validation:

Use of QCDR that shows performance of activities promoting shared clinical decision making capabilities

Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities

Subcategory Name:

Beneficiary Engagement

Activity Description:

Enhancements and ongoing regular updates and use of websites/tools that include consideration for compliance with section 508 of the Rehabilitation Act of 1973 or for improved design for patients with cognitive disabilities. Refer to the CMS website on Section 508 of the Rehabilitation Act https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information...? redirect=/InfoTechGenInfo/07_Section508.asp that requires that institutions receiving federal funds solicit, procure, maintain and use all electronic and information technology (EIT) so that equal or alternate/comparable access is given to members of the public with and without disabilities. For example, this includes designing a patient portal or website that is compliant with section 508 of the Rehabilitation Act of 1973

Activity Validation:

Practice website/tools are regularly updated and enhanced and are Section 508 compliant

Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.

Subcategory Name:

Beneficiary Engagement

Activity Description:

Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.

Activity Validation:

Use of patient experience data from the QCDR to inform and advance improvements in beneficiary engagement

Suggested Documentation:

Participation in QCDR to inform and advance improvements in beneficiary engagement , e.g., regular feedback reports provided by the QCDR that show participation in the use of patient experience measures/activities in informing and advancing beneficiary engagement

ID: IA_BE_10

Weighting: Medium

Participation in a QCDR, that promotes implementation of patient self-action plans.

Subcategory Name:

Beneficiary Engagement

Activity Description:

Participation in a QCDR, that promotes implementation of patient self-action plans.

Activity Validation:

Participation in a QCDR to promote implementation of patient self-action plans

Suggested Documentation:

Participation in QCDR that promotes implementation of patient self-action plans, e.g., regular feedback reports provided by the QCDR that show the promotion and use of patient self action plans

ID: IA_BE_11

Weighting: Medium

Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.

Subcategory Name:

Beneficiary Engagement

Activity Description:

Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.

Activity Validation:

Participation in a QCDR to promote use of processes and tools to engage patients to adhere to treatment plans

Suggested Documentation:

Participation in QCDR promoting engagement of patients for adherence to treatment plans, e.g., regular feedback reports provided by the QCDR showing the promotion of processes and tools that engage patients for adherence to treatment plans

ID: IA_BE_12

Weighting: Medium

Use evidence-based decision aids to support shared decision-making.

Subcategory Name:

Beneficiary Engagement

Activity Description:

Use evidence-based decision aids to support shared decision-making.

Activity Validation:

Use of evidence based decision aids to support shared decision-making with beneficiary

Suggested Documentation:

Documentation (e.g. checklist, algorithms, tools, screenshots) showing the use of evidence-based decision aids to support shared decision-making with beneficiary

Engage Patients and Families to Guide Improvement in the System of Care

Subcategory Name:

Beneficiary Engagement

Activity Description:

Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient’s status, adherence, comprehension, and indicators of clinical concern.

Activity Validation:

Functionality of methods to engage patients and families in improving the system of care

Suggested Documentation:

Documentation showing patient and family engagement, e.g. meeting agendas and summaries where patients families have been engaged, survey results from patients and/or families; and improvements made in the system of care

ID: IA_BE_15

Weighting: Medium

Engagement of patients, family and caregivers in developing a plan of care

Subcategory Name:

Beneficiary Engagement

Activity Description:

Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.

Activity Validation:

Inclusion of patients, family and caregivers in plan of care and prioritizing goals for action, as documented in certified EHR.

Suggested Documentation:

Report from the certified EHR, showing the plan of care and prioritized goals for action with engagement of the patient, family and caregivers, if applicable

Functionality of evidence based techniques to promote self-management into usual care

Suggested Documentation:

Documented evidence-based techniques to promote self-management into usual care; and evidence of the use of the techniques (e.g. clinicians' completed office visit checklist, EHR report of completed checklist)

ID: IA_BE_17

Weighting: Medium

Use of tools to assist patient self-management

Subcategory Name:

Beneficiary Engagement

Activity Description:

Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How’s My Health).

Activity Validation:

Use of tools to assist patient self-management

Suggested Documentation:

Documentation in patient record or EHR showing use of Patient Activation Measure, How's My Health, or similar tools to assess patients need for support for self-management

ID: IA_BE_18

Weighting: Medium

Provide peer-led support for self-management.

Subcategory Name:

Beneficiary Engagement

Activity Description:

Provide peer-led support for self-management.

Activity Validation:

Use of peer-led self-management

Suggested Documentation:

Documentation in medical record or EHR of peer-led self-management program

ID: IA_BE_19

Weighting: Medium

Use group visits for common chronic conditions (e.g., diabetes).

Subcategory Name:

Beneficiary Engagement

Activity Description:

Use group visits for common chronic conditions (e.g., diabetes).

Activity Validation:

Use of group visits for chronic conditions. Could be supported by claims.

Suggested Documentation:

Medical claims or referrals showing group visit and chronic condition codes in conjunction with care provided

Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.

Activity Validation:

Use of condition-specific chronic disease self-management programs or coaching or link to community programs

Suggested Documentation:

1) Chronic Disease Self-Management Support Program - Documentation from medical record or EHR showing condition specific chronic disease self-management support program or coaching; or2) Community Chronic Disease Self-Management Support Program - Documentation of referral/link of patients to condition specific chronic disease self-management support programs in the community

Provide self-management materials at an appropriate literacy level and in an appropriate language.

Activity Validation:

Provision of self-management materials appropriate for literacy level and language

Suggested Documentation:

Documented provision in EHR or medical record of self-management materials, e.g., pamphlet, discharge summary language, or other materials that include self management materials appropriate for the patient's literacy and language

ID: IA_BE_22

Weighting: Medium

Improved Practices that Engage Patients Pre-Visit

Subcategory Name:

Beneficiary Engagement

Activity Description:

Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.

Activity Validation:

Pre-visit agenda shared with patient

Suggested Documentation:

Documentation of a letter, email, portal screenshot, etc. that shows a pre-visit agenda was shared with patient

ID: IA_BE_23

Weighting: Medium

Integration of patient coaching practices between visits

Subcategory Name:

Beneficiary Engagement

Activity Description:

Provide coaching between visits with follow-up on care plan and goals.

Activity Validation:

Use of coaching between visits with follow-up on care plan and goals. Could be supported by claims.

Documentation from an AHRQ-listed patient safety organization (PSO) confirming the eligible clinician or group's participation with the PSO. PSOs listed by AHRQ are here: http://www.pso.ahrq.gov/listed

ID: IA_PSPA_2

Weighting: Medium

Participation in MOC Part IV

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Participation in Maintenance of Certification (MOC) Part IV, such as the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical Quality Coach, Quality Practice Initiative Certification Program, American Board of Medical Specialties Practice Performance Improvement Module or ASA Simulation Education Network, for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program. Performance of monthly activities across practice to regularly assess performance in practice, by reviewing outcomes addressing identified areas for improvement and evaluating the results.

Activity Validation:

Participation in MOC Part IV including a local, regional, or national outcomes registry or quality assessment program and performance of monthly activities to assess and address practice performance

Suggested Documentation:

1) Participation in Maintenance of Certification from ABMS Member Board - Documentation of participation in Maintenance of Certification (MOC) Part IV from an ABMS member board including participation in a local, regional or national outcomes registry or quality assessment program; and2) Monthly Activities to Assess Performance - Documented performance of monthly activities across practice to assess performance in practice by reviewing outcomes, addressing areas of improvement, and evaluating the results

ID: IA_PSPA_3

Weighting: Medium

Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or Other Similar Activity

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

For MIPS eligible clinicians not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as the Institute for Healthcare Improvement (IHI) Training/Forum Event; National Academy of Medicine, Agency for Healthcare Research and Quality (AHRQ) Team STEPPS®, or the American Board of Family Medicine (ABFM) Performance in Practice Modules.

Activity Validation:

Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or other similar activity.

Suggested Documentation:

Certificate or letter of participation from an IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or other similar activity, for eligible clinicians or groups not participating in MOC Part IV

ID: IA_PSPA_4

Weighting: Medium

Administration of the AHRQ Survey of Patient Safety Culture

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetycu...).Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.

Activity Validation:

Administration of the AHRQ survey of Patient Safety Culture and submission of data to the comparative database

Suggested Documentation:

Survey results from the AHRQ Survey of Patient Safety Culture, including proof of administration and submission

ID: IA_PSPA_5

Weighting: Medium

Annual registration in the Prescription Drug Monitoring Program

Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months.

Activity Validation:

Annual registration in the prescription drug monitoring program of the state and participation for a minimum of 6 months

Suggested Documentation:

1) Activation/Registration of an PDMP Account - Documentation evidencing activation/registration of an PDMP account (e.g. an email), and2) Participation in PDMP - Evidence of participating in the PDMP, i.e., accessing/consulting (e.g. copies of patient reports created, with the PHI masked)

ID: IA_PSPA_6

Weighting: High

Consultation of the Prescription Drug Monitoring Program

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Clinicians would attest to reviewing the patients’ history of controlled substance prescription using state prescription drug monitoring program (PDMP) data prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription lasting longer than 3 days. For the transition year, clinicians would attest to 60 percent review of applicable patient’s history. For the Quality Payment Program Year 2 and future years, clinicians would attest to 75 percent review of applicable patient’s history performance.

Activity Validation:

Provision of consulting with PDMP before issuance of a controlled substance schedule II opioid prescription that lasts longer than 3 days

Suggested Documentation:

1) Number of Issuances of CSII Prescription - Total number of issuances of a CSII prescription that lasts longer than 3 days over the same time period as those consulted; and2) Documentation of Consulting the PDMP - Total number of patients for which there is evidence of consulting the PDMP prior to issuing an CSII prescription (e.g. copies of patient reports created, with the PHI masked)

ID: IA_PSPA_7

Weighting: Medium

Use of QCDR data for ongoing practice assessment and improvements

Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

Use of QCDR data, for ongoing practice assessment and improvements in patient safety.

Activity Validation:

Use of QCDR data for ongoing practice assessment and improvements in patient safety

Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of a surgical risk calculator, evidence based protocols such as Enhanced Recovery After Surgery (ERAS) protocols, the CDC Guide for Infection Prevention for Outpatient Settings, (https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html), predictive algorithms, or other such tools.

Activity Validation:

Use of tools by specialty practices in tracking specific meaningful patient safety and practice assessment measures

Suggested Documentation:

Documentation of the use of patient safety tools, e.g. surgical risk calculator, that assist specialty practices in tracking specific patient safety measures meaningful to their practice

ID: IA_PSPA_9

Weighting: Medium

Completion of the AMA STEPS Forward program

Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

Completion of the American Medical Association’s STEPS Forward program.

Activity Validation:

Completion of AMA STEPS Forward program

Suggested Documentation:

Certificate of completion from AMA's STEPS Forward program

ID: IA_PSPA_10

Weighting: Medium

Completion of training and receipt of approved waiver for provision of opioid medication-assisted treatments

Subcategory Name:

Patient Safety & Practice Assessment

Activity Description:

Completion of training and obtaining an approved waiver for provision of medication -assisted treatment of opioid use disorders using buprenorphine.

Activity Validation:

Completion of training and obtaining approved waiver for provision of medication assisted treatment of opioid use disorders using buprenorphine

Practice documents that show participation in Joint Commission's Ongoing Professional Practice Evaluation initiative

ID: IA_PSPA_14

Weighting: Medium

Participation in Quality Improvement Initiatives

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Participation in other quality improvement programs such as Bridges to Excellence or American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.

Activity Validation:

Participation in other quality improvement programs such as Bridges to Excellence

Suggested Documentation:

Documentation from Bridges to Excellence or other similar program confirming participation in its improvement program(s)

ID: IA_PSPA_15

Weighting: Medium

Implementation of an ASP

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Change Activity Description to: Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, bronchitis treatment in adults) according to clinical guidelines for diagnostics and therapeutics. Specific activities may include:

• Lead the development, implementation, and monitoring of patient care and patient safety protocols for the delivery of ASP including protocols pertaining to the most appropriate setting for such services (i.e., outpatient or inpatient).

• Assist in improving ASP service line efficiency and effectiveness by evaluating and recommending improvements in the management structure and workflow of ASP processes.

• Manage compliance of the ASP policies and assist with implementation of corrective actions in accordance with facility or clinic compliance policies and hospital medical staff by-laws.

• Lead the education and training of professional support staff for the purpose of maintaining an efficient and effective ASP.

• Coordinate communications between ASP management and facility or practice personnel regarding activities, services, and operational/clinical protocols to achieve overall compliance and understanding of the ASP.

• Assist, at the request of the facility or practice, in preparing for and responding to third-party requests, including but not limited to payer audits, governmental inquiries, and professional inquiries that pertain to the ASP service line.

• Developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections.

• Implementing evidence-based protocols that align with recommendations in the Centers for Disease Control and Prevention’s Core Elements of Outpatient Antibiotic Stewardship guidance

Activity Validation:

Functionality of an antibiotic stewardship program

Suggested Documentation:

Documentation of implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions according to clinical guidelines for diagnostics and therapeutics and identifies improvement actions

ID: IA_PSPA_16

Weighting: Medium

Use of decision support and standardized treatment protocols

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.

Activity Validation:

Use of decision support and treatment protocols to manage workflow in the team to meet patient needs

Suggested Documentation:

Documentation (e.g. checklist, algorithm, screenshot) showing use of decision support and standardized treatment protocols to manage workflow in the team to meet patient needs

ID: IA_PSPA_17

Weighting: Medium

Implementation of analytic capabilities to manage total cost of care for practice population

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Build the analytic capability required to manage total cost of care for the practice population that could include one or more of the following:

Use available data regularly to analyze opportunities to reduce cost through improved care.

Activity Validation:

Use of analytic capabilities to manage total cost of care for practice population

Suggested Documentation:

1) Staff Training - Documentation of staff training on interpretation of cost and utilization information (e.g. training certificate); or2) Cost/Resource Use Data - Availability of cost/resource use data for the practice population that is used regularly to analyze opportunities to reduce cost

ID: IA_PSPA_18

Weighting: Medium

Measurement and Improvement at the Practice and Panel Level

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards, that could include one or more of the following:

• Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group (panel); and/or

• Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level.

Activity Validation:

Measure and improve quality at the practice and panel level

Suggested Documentation:

1) Quality Improvement Program/Plan at Practice and Panel Level - Copy of a quality improvement program/plan or review of quality, utilization, patient satisfaction and other measures to improve one or more elements of this activity; or2) Review of and Progress on Measures - Report showing progress on selected measures, including benchmarks and goals for performance using relevant data sources at the practice and panel level

• Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.

Activity Validation:

Implementation of a formal model for quality improvement and creation of a culture in which staff actively participates in one or more improvement activities

Suggested Documentation:

1) Adopt Formal Quality Improvement Model and Create Culture of Improvement - Documentation of adoption of a formal model for quality improvement and creation of a culture in which staff actively participate in improvement activities; and2) Staff Participation - Documentation of staff participation in one or more of the six identified; including, training, integration into staff duties, identifying and testing practice changes, regular team meetings to review data and plan improvement cycles, share practice and panel level quality of care, patient experience and utilization data with staff, or share practice level quality of care, patient experience and utilization data with patients and families

Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).

Activity Validation:

Functionality of fall screening and assessment programs

Suggested Documentation:

1) Implementation of a Falls Screening and Assessment Program - Implementation of a falls screening and assessment program that uses valid and reliable tools to identify patients at risk for falls and address modifiable risk factors, for example, the STEADI program for identification of falls risk; and2) Implementation Progress- Documentation of progress made on falls screening and assessment after implementation of tool

Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course “Applying CDC’s Guideline for Prescribing Opioids” that reviews the 2016 “Guideline for Prescribing Opioids for Chronic Pain.” Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.

ID: IA_PSPA_23

Weighting: High

Completion of CDC Training on Antibiotic Stewardship

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Completion of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.

ID: IA_PSPA_24

Weighting: Medium

Initiate CDC Training on Antibiotic Stewardship

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Completion of greater than 50 percent of the modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis, but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.

ID: IA_PSPA_25

Weighting: Medium

Cost Display for Laboratory and Radiographic Orders

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Implementation of a cost display for laboratory and radiographic orders, such as costs that can be obtained through the Medicare clinical laboratory fee schedule.

ID: IA_PSPA_26

Weighting: Medium

Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

A MIPS eligible clinician providing unscheduled care (such as an emergency room, urgent care, or other unplanned encounter) attests that, for greater than 75 percent of case visits that result from a clinically significant adverse drug event, the MIPS eligible clinician provides information, including through the use of health IT to the patient’s primary care clinician regarding both the unscheduled visit and the nature of the adverse drug event within 48 hours. A clinically significant adverse event is defined as a medication-related harm or injury such as side-effects, supratherapeutic effects, allergic reactions, laboratory abnormalities, or medication errors requiring urgent/emergent evaluation, treatment, or hospitalization.

ID: IA_PSPA_27

Weighting: Medium

Invasive Procedure or Surgery Anticoagulation Medication Management

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

For an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, including patients taking vitamin K antagonists (warfarin), target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, documentation, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient’s anticoagulation. Elements of the plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)). An invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.

ID: IA_PSPA_28

Weighting: Medium

Completion of an Accredited Safety or Quality Improvement Program

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Completion of an accredited performance improvement continuing medical education program that addresses performance or quality improvement according to the following criteria:• The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;• The activity must have specific, measurable aim(s) for improvement;• The activity must include interventions intended to result in improvement;• The activity must include data collection and analysis of performance data to assess the impact of the interventions; andThe accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.

ID: IA_PSPA_29

Weighting: High

Consulting AUC Using Clinical Decision Support when Ordering Advanced

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Clinicians attest that they are consulting specified applicable AUC through a qualified clinical decision support mechanism for all applicable imaging services furnished in an applicable setting, paid for under an applicable payment system, and ordered on or after January 1, 2018. This activity is for clinicians that are early adopters of the Medicare AUC program (2018 performance year) and for clinicians that begin the Medicare AUC program in future years as specified in our regulation at §414.94. The AUC program is required under section 218 of the Protecting Access to Medicare Act of 2014. Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.

ID: IA_PSPA_30

Weighting: High

PCI Bleeding Campaign

Subcategory Name:

Patient Safety and Practice Assessment

Activity Description:

Participation in the PCI Bleeding Campaign which is a national quality improvement program that provides infrastructure for a learning network and offers evidence-based resources and tools to reduce avoidable bleeding associated with patients who receive a percutaneous coronary intervention (PCI).

The program uses a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for PCI patients by implementing quality improvement strategies:• Radial-artery access,• Bivalirudin, and• Use of vascular closure devices.

ID: IA_AHE_1

Weighting: High

Engagement of New Medicaid Patients and Follow-up

Subcategory Name:

Achieving Health Equity

Activity Description:

Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity.

Activity Validation:

Functionality of practice in seeing new and follow-up Medicaid patients in a timely manner including patients dually eligible

Suggested Documentation:

1) Timely Appointments for Medicaid and Dually Eligible Medicaid/Medicare Patients - Statistics from certified EHR or scheduling system (may be manual) on time from request for appointment to first appointment offered or appointment made by type of visit for Medicaid and dual eligible patients; and2) Appointment Improvement Activities - Assessment of new and follow-up visit appointment statistics to identify and implement improvement activities

ID: IA_AHE_2

Weighting: Medium

Leveraging a QCDR to standardize processes for screening

Subcategory Name:

Achieving Health Equity

Activity Description:

Participation in a QCDR, demonstrating performance of activities for use of standardized processes for screening for social determinants of health such as food security, employment and housing. Use of supporting tools that can be incorporated into the certified EHR technology is also suggested.

Activity Validation:

Participation in a QCDR and demonstrated performance of activities for use of standardized processes for screening for social determinants of health including use of supporting tools into certified EHR technology

Suggested Documentation:

1) QCDR for Standardizing Screening Processes - Participation in QCDR for standardizing screening processes for social determinants, e.g., regular feedback reports from QCDR showing screening practices for social determinants; and2) Integration of Tools into Certified EHR (suggested) - Integration of one or more of the following tools into practice as part of the EHR, e.g., http://www.cdc.gov/socialdeterminants /tools/index.htm showing regular referral to one or more of these tools

ID: IA_AHE_3

Weighting: High

Promote Use of Patient-Reported Outcome Tools

Subcategory Name:

Achieving Health Equity

Activity Description:

Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PQH-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.

Activity Validation:

Participation in a QCDR and demonstrated performance of activities to promote use of patient-report outcome tools and corresponding collection of PRO data

Suggested Documentation:

Participation in QCDR, for use of patient-reported outcome tools, e.g., regular QCDR feedback reports demonstrating use of patient-reported outcome tools and corresponding collection of PRO data, e.g., use of PHQ-2 or PHQ-9 and PROMIS instruments

Participation in a QCDR and demonstrated performance of activities for use of standard questionnaires for assessing improvement in health disparities related to functional health status

Suggested Documentation:

Participation in QCDR, to use of standard questionnaires for assessing improvements in health disparities, e.g., regular feedback reports from QCDR, demonstrating performance of activities for using standard questionnaires for assessing improvements in health disparities related to functional health status

ID: IA_AHE_5

Weighting: Medium

MIPS Eligible Clinician Leadership in Clinical Trials or CBPR

Subcategory Name:

Achieving Health Equity

Activity Description:

MIPS eligible clinician leadership in clinical trials, research alliances or community-based participatory research (CBPR) that identify tools, research or processes that can focuses on minimizing disparities in healthcare access, care quality, affordability, or outcomes.

ID: IA_AHE_6

Weighting: High

Provide Education Opportunities for New Clinicians

Subcategory Name:

Achieving Health Equity

Activity Description:

MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.

Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.

Activity Validation:

Participation in Disaster Medical Assistance Team or Community Emergency Responder Team for at least 6 months as a volunteer

Suggested Documentation:

Documentation of participation in Disaster Medical Assistance or Community Emergency Responder Teams for at least 6 months including registration and active participation, e.g., attendance at training, on-site participation, etc.

ID: IA_ERP_2

Weighting: High

Participation in a 60-day or greater effort to support domestic or international humanitarian needs.

Subcategory Name:

Emergency Response & Preparedness

Activity Description:

Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.

Activity Validation:

Participation in domestic or international humanitarian volunteer work of at least a continuous 60 days duration

Suggested Documentation:

Documentation of participation in domestic or international humanitarian volunteer work of at least a continuous 60 days duration including registration and active participation, e.g., identification of location of volunteer work, timeframe, and confirmation from humanitarian organization

ID: IA_BMH_1

Weighting: Medium

Diabetes screening

Subcategory Name:

Behavioral and Mental Health

Activity Description:

Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.

Activity Validation:

Performance of diabetes screening for patients with schizophrenia or bipolar disease who are using antipsychotic medication

Suggested Documentation:

Report from certified EHR, documentation from medical charts, or claims showing regular practice for diabetes screening of patients with schizophrenia or bipolar disease who are using antipsychotic medications

ID: IA_BMH_2

Weighting: Medium

Tobacco use

Subcategory Name:

Behavioral and Mental Health

Activity Description:

Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.

Activity Validation:

Performance of regular engagement in integrated prevention and treatment interventions including tobacco use screening and cessation interventions for patients with co-conditions of behavioral or mental health and at risk factors for tobacco dependence

Suggested Documentation:

Report from certified EHR, QCDR, clinical registry or documentation from medical charts showing regular practice of tobacco screening for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence

Performance of regular engagement in integrated prevention and treatment interventions for patients with co-occurring conditions of behavioral or mental health and at risk factors for unhealthy alcohol use

Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.

Activity Validation:

Performance of regular engagement in integrated prevention and treatment interventions including depression screening and follow-up plan for patients with co-conditions of behavioral or mental health

Suggested Documentation:

Report from certified EHR, QCDR, clinical registry or documentation from medical charts showing regular practice for depression screening and follow-up plan for these patients with co-conditions of behavioral or mental health

Offer integrated behavioral health services to support patients with behavioral health needs who also have conditions such as dementia or other poorly controlled chronic illnesses. The services could include one or more of the following:

• Use evidence-based treatment protocols and treatment to goal where appropriate;

• Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;

• Participate in the National Partnership to Improve Dementia Care Initiative, which promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training, and revised surveyor guidance.

Documented integration of behavioral health services with primary care to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions program and services including one or more of the six activities described in the activity description

ID: IA_BMH_8

Weighting: Medium

Electronic Health Record Enhancements for BH data capture

Subcategory Name:

Behavioral and Mental Health

Activity Description:

Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).

Activity Validation:

Use of EHR to capture additional data on behavioral health populations and use data for additional decision-making

Suggested Documentation:

Screen shots from certified EHR or from other software/tools integrated with the certified EHR and reports showing how additional behavioral health data is captured and used for additional decision-making

ID: IA_BMH_9

Weighting: High

Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients

Subcategory Name:

Behavioral And Mental Health

Activity Description:

Individual MIPS eligible clinicians or groups must regularly engage in integrated prevention and treatment interventions, including screening and brief counseling (for example: NQF #2152) for patients with co-occurring conditions of mental health and substance abuse. MIPS eligible clinicians would attest that 60 percent for the CY 2018 Quality Payment Program performance period, and 75 percent beginning in the 2019 performance period, of their ambulatory care patients are screened for unhealthy alcohol use.

ID: IA_PCMH

Weighting: N/A

Electronic submission of Patient Centered Medical Home accreditation

Subcategory Name:

N/A

Activity Description:

N/A

Activity Validation:

Performance of standards and expectation that pertain to the patient-centered medical home model.

Suggested Documentation:

1) Documented implementation of patient-centered medical home activities and improvements that pertain to care coordination, patient-centeredness, or comprehensiveness of care, among others; or2) Documented recognition as a patient-centered medical home from accredited body, combined with continual improvements